“Hello, you have reached the UM Department. We are open Monday through Friday, 8 a.m. to 5 p.m. Please leave your name and number and we will return your call.”
– A Large Health Plan in CA
Imagine this: You are a nurse case manager at a busy hospital in Southern California. It is 3 a.m. in the morning on a Saturday in late July. A patient arrives on a stretcher via ambulance with gunshot wounds to the chest. Emergency nurses and assisting medical staff are rushing to stabilize the patient to save their life. Finally, an hour later, the patient is stabilized, but requires post-stabilization care for their injuries. As the case manager, you discover that the patient has Careless Health Plan. Knowing your responsibilities, you quickly call the Careless UM Department to notify them of the patient’s condition and request authorization to admit the patient or prepare the patient for transfer. The phone rings and rings and rings until finally, a voice picks up, but before you can speak, you realize that it is an automated message. You are informed that Careless UM department is open from 8 a.m. to 5 p.m. Monday through Friday, and you must leave a message. They will return your call during normal operating hours.
You are sitting at your nurse station thinking, “What do I do?” The treating physician then approaches you and demands that the patient be admitted for post-stabilization care. Knowing that you are not going to get approval from Careless, you admit the patient into the facility for care and treatment. Upon arrival to the hospital on Monday morning, you promptly call Careless UM Department at 8 a.m. and advise of the admission. Careless requests all medical records and information which you quickly gather and fax. As you are awaiting the response from Careless, the patient is discharged home. Careless then calls you to inform you that the inpatient services have been denied as not medically necessary. As a result, the patient incurs $90,000 in inpatient services that were denied.
This nightmare situation haunts all providers in the State of California.
All Knox Keene enrollees licensed in the state of California are legally required to maintain 24 hour provider access if the health plan requires prior authorization as a prerequisite for payment of necessary medical care following stabilization of an emergency medical condition or active labor.
CA HEALTH PLANS REQUIRING AUTHORIZATION FOR POST-STABLIZATION NECESSARY CARE ARE REQUIRED TO MAINTAIN 24 HOUR PROVIDER AND ENROLLEE ACCESS
According to CA Health and Safety Code § 1371.4(a)
(a) A health care service plan that covers hospital, medical, or surgical expenses, or its contracting medical providers, shall provide 24-hour access for enrollees and providers, including, but not limited to, noncontracting hospitals, to obtain timely authorization for medically necessary care, for circumstances where the enrollee has received emergency services and care is stabilized, but the treating provider believes that the enrollee may not be discharged safely. A physician and surgeon shall be available for consultation and for resolving disputed requests for authorizations. A health care service plan that does not require prior authorization as a prerequisite for payment for necessary medical care following stabilization of an emergency medical condition or active labor need not satisfy the requirements of this subdivision.
Under existing California law, all Knox Keene enrollees licensed in the state of California are legally required to maintain 24 hour provider access if the health plan requires prior authorization as a prerequisite for payment of necessary medical care following stabilization of an emergency medical condition or active labor.
In the Health Care industry, it is common knowledge that for post-stabilization care, most health plans require prior authorization which usually happens in the form of a fax or a call to the health plan advising them that the patient is stable and ready for post-stabilization care via admission or provide the health plan with the opportunity to assume care of the patient in accordance with CA Health and Safety Code § 1262.8 and § 1371.4(j).
It is a fair assumption to make as the Department of Managed Health Care has provided a detailed list of Knox Keene enrollees who maintain 24/7 contact in their UM Department for providers to contact. However, Careless is conveniently absent from this list.
Our office had a conversation with a DMHC official who informed our office that the plan does not maintain a 24 hour UM department for providers as required by CA state law, but that the plan will not deny any post-stabilization care occurring after normal business hours or on the weekends when they are not open.
Our office recently received a case from a provider member regarding a situation similar to the one in the introduction. The patient in this case arrived at the hospital with an emergency medical condition and received emergency medical treatment as well as post-stabilization care. The patient arrived at the hospital on a Friday and was admitted in the late afternoon. The provider never attempted to call the health plan for authorization until the next business day which was Monday when they faxed all clinical information to the plan. The patient was admitted for two days. The plan ultimately approved one day and denied the second day claiming that the stay was not authorized. After the hospital exhausted their efforts with the plan to overturn the second day denial, our office submitted a Notice of Intent to File a Complaint (NOIFC) with the Department of Managed Health Care (DMHC) to the plan’s Legal Counsel.
Our letter was a result of an investigation into the plan’s policies and procedures that revealed something disturbing. Back in 2012, our office had a conversation with a DMHC official who informed our office that the plan does not maintain a 24 hour UM department for providers as required by CA state law, but that the plan will not deny any post-stabilization care occurring after normal business hours or on the weekends when they are not open.
After learning about this conversation, I became very concerned and anxious as this was nothing more than a conversation that the plan may have made an illegal agreement to violate the law with the regulatory agency that monitors and enforces CA Health and Safety codes. As our NOIFC was being reviewed with the plan, our office sent an email to the DMHC requesting information and clarification of this agreement and made a public records request for any written document memorializing this conversation.
On 11/2/17, one of the plan’s attorneys sent our office a letter that incorrectly stated that the patient did not present with an emergency medical condition and received emergency medical treatment as they were not admitted through the ER. Their position flatly contradicts both the law and the patient’s medical condition via records, however the plan ultimately agreed to reimburse the Provider for the additional day. They reasoned that they wanted to avoid litigation on this matter. …Interesting.
Subsequently, on 11/17/17 our office received a response from the DMHC. They provided a number of documents that were responsive to our request, but one letter in particular explains everything. DMHC amended exhibit E-1 states in relevant part that, “the plan is confirming that it does not require prior authorization as a prerequisite for payment for necessary medical care following stabilization of an emergency medical condition or active labor, pursuant to Health & Safety Code Section 1371.4”.
Talk about being caught.
There are many laws and regulations that govern health insurance plans nationwide. It is a complex universe of rules and exceptions. Naturally, there are health plans and capitated providers that will attempt to circumvent the laws and attempt to take advantage of the financial gains that result in violating the law. They continuously attempt to find ways to reimburse providers as little as possible via contracts with providers, letters of agreements and other methods. As providers and advocates, it is our duty to ensure health plans are operating within the confines of the law and hold them responsible and accountable when they attempt to thwart the law and public safety. This ensures that providers are able to capture revenue and administer medically appropriate heath care to patients.
If you are a provider member who has experienced the above situation in any state, we would like to hear from you to determine the health plan’s responsibilities in regards to their UM Department and their hours of operation for providers and enrollee’s.
ERN/ The Reimbursement Advocacy Firm
Brian Ford, J.D., CCA & Writer
(714) 995-6900 ext. 6920
This post was written by ernncra